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CP3 Medicine > Cardiology p2 > Flashcards

Cardiology p2 Flashcards

(73 cards)

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1
Q

What is congestive cardiac failure?

A

Structural/functional disorder affecting ability to function as a pump

Either caused by impaired left ventricular contraction (“systolic heart failure”) or left ventricular relaxation (“diastolic heart failure”). This impaired left ventricular function results in a chronic back-pressure of blood trying to flow into and through the left side of the heart

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2
Q

What is cardiac output made up of?

A

pre-load
afterload
myocardial contractility

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3
Q

What adaptations occur to the heart in CCF?

A

Decreased CO: activation of SNS and RAAS

RAAS leads to vasoconstriction and increased water and sodium retention. increases BP and cardiac work

SNS leads to myocyte apoptosis and necrosis

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4
Q

What are the causes of CCF commonly?

A

Ischaemic Heart Disease
Valvular Heart Disease (commonly aortic stenosis)
Hypertension
Arrhythmias (commonly atrial fibrillation)

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5
Q

What are the more rare causes of CCF?

A 
congenital heart disease
Cor pulmonale
Alcohol/drugs
AF
Heart block
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6
Q

What is the most common cause of RHF?

A

LHF

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7
Q

What is the presentation of LHF?

A

fatigue
exertional dyspnoea
paroxysmal nocturnal dyspnoea
orthopnoea

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8
Q

What are the examination findings of LHF?

A

Cardiomegaly + displaced apex beat

3rd heart sound, gallop rhythm
bi-basal coarse crackles

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9
Q

What is the presentation of RHF?

A

breathless
fatigue
anorexia
swollen ankles

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10
Q

What are the signs of RHF?

A 
Increased JVP
Splenomegaly
Pitting oedema 
Pleural effusion
Cardiomegaly/gallop rhythm
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11
Q

What investigations would you do for CCF?

A

Bloods - FBC, U+E, LFT, TFT, cardiac enzymes

BNP: normal excludes heart failure

CXR: cardiomegaly and pulmonary oedema

ECG: ischaemia, HTN or arrhythmia

Ejection fraction <45% is diagnostic

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12
Q

What further investigations can be done for CCF?

A

Cardiac MRI, cardiac catheter (measure pressure) or functional testing

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13
Q

What is the NYHA classification?

A

I - disease present, no undue dyspnoea from normal activity

II - dyspnoea present, on ordinary activities

III - less than ordinary activity causes dyspnoea which is limiting

IV - dyspnoea at rest, any activity causes discomfort

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14
Q

What is the management of LV failure?

A

Lifestyle:
vaccines
stop smoking
exercise as tolerated

Medical:
ABAL:
A:ACE inhibitor: Ramipril (titrated to 10mg o.d)
B: Beta blocker: bisoprolol titrated to 10mg o.d.)
A: Aldosterone receptor antagonist
L: Loop diuretic (furosemide 40mg) for symptoms

Third line: digoxin

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15
Q

What are the lifestyle measures for CCF?

A

Obesity control and diet (decrease salt and fluid intake)
stop smoking
physical activity
vaccination (pneumococcal vaccine)
Sex - don’t take viagra (causes hypotension)

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16
Q

What ACEis should be given for CCF?

A

ramipril, lisinopril
low dose and titrate up to 10mg once a day
don’t use with NSAIDs (renal damage)

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17
Q

What are the Side effects of ACEi?

A

Dry cough (give candesartan 32mg if this is the case)

Renal side effects so monitor U+Es

First dose hypotension - give at night

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18
Q

Which diuretics are used in CCF?

A

thiazides - bendroflumethiazide

Loop - furosemide

both can cause hypokalaemia

Spironolactone (potassium sparing)

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19
Q

What is digoxin?

A

+ve inotrope and -ve chronotrope SO increases force and decreases heart rate

Inhibits Na/K pump and leads to Na+ accumulation
contra-indicated in heart block and bradycardia

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20
Q

What are the causes of valvular heart disease?

A

Degenerative
Rheumatic fever
Congenital
Ischaemic

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21
Q

Describe how infection causes valvular heart disease?

A 
Immune mediated (rheum)
or direct: bacterial/functional endocarditis

result is:
collagen exposure and thrombus development
post-inflammatory scarring - functional impairment

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22
Q

Which side of the heart is more commonly affected in endocarditis?

A

LH - emboli can affect systemic organs

Mitral valve most commonly affected

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23
Q

What is the most common cause of chronic valve scarring?

A

Rheumatic fever

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24
Q

What is rheumatic fever caused by?

A

Group A B haemolytic streptococci

Antibody production to GAS cross reacts with cardiac antigens causing a self-limiting myocarditis

damage to valves - fibrosis so you get shrunken, fibrotic valves

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25
What congenital causes of valvular disease are there?
Congenital bi-cuspid aortic valve - calcification --> aortic stenosis
26
How does ischaemic cause valvular heart disease?
Infarction --> papillary muscle dysfunction leads to mitral regurgitation
27
What are the causes of aortic stenosis?
Calcification of congenital bicuspid valve rheumatic fever Senile calcific degeneration
28
Describe the pathology of aortic stenosis
Progressive outflow obstruction leads to LV hypertrophy and angina risk of sudden cardiac death due to arrhythmias
29
What are the symptoms of aortic stenosis?
syncope, angina and dyspnoea on exercise
30
What are the signs of aortic stenosis?
EJECTION systolic high pitched murmur (aortic region to carotid) Pulse: small volume, slow rising BP: narrow pulse pressure crescendo-decrescendo murmur
31
What are the treatments for aortic stenosis?
Valve replacement | percutaneous valvuloplasty
32
What are the causes of mitral regurgitation?
idiopathic weakening of the valve with age Ischaemic heart disease Infective Endocarditis Rheumatic Heart Disease Connective tissue disorders such as Ehlers Danlos syndrome or Marfan syndrome
33
What are the symptoms of mitral regurg?
Incompetent mitral valve allows blood to leak back through during systolic contraction of the left ventricle AF - palpitation pulmonary HTN - SOB/orthopnoea Fatigue
34
What are the signs of mitral regurg?
pan-systolic, high pitched “whistling” murmur due to high velocity blood flow through the leaky valve. The murmur radiates to left axilla. You may hear a third heart sound laterally displaced apex beat + systolic thrill LHF/RHF
35
What is the mx of mitral regurg?
treat heart failure echo surgery if deteriorate
36
What are the causes of aortic regurg?
post inflammatory scarring infective endocarditis age-related calcification dilation of aortic root due to inflammatory disease Connective tissue disorders such as Ehlers Danlos syndrome or Marfan syndrome
37
What are the symptoms of aortic regurg?
asymptomatic until acute left ventricular failure angina pectoris and dyspnoea
38
What are the signs of aortic regurg?
early diastolic, soft murmur. It is also associated with a Corrigan’s pulse (bounding/collapsing pulse) wide pulse pressure signs of LVF
39
What are the signs of severe aortic regurg?
Quinke's - pulsation in nail bed DeMusset - nodding Durozies - femoral murmur pistol shot femoral (bang if auscultated)
40
What is the management of aortic regurg?
replace valve before significant LV dysfunction
41
What is the cause of mitral stenosis?
Rheumatic fever - post inflammatory scarring Infective endocarditis
42
Describe the pathophysiology of mitral stenosis
LA can't empty pulmonary HTN LA dilates and hypertrophies --> AF Pulmonary HTN: RHF
43
What are the symptoms of MS?
pulmonary HTN: SOB and haemoptysis RHF: fatigue, weakness, limb oedema AF - palpitation
44
What are the signs of MS?
``` rumbling MID DIASTOLIC murmur Malar flush small volume pulse jugular vein distortion left parasternal heave ``` AF
45
What is the management of MS?
Treat AF Diuretics Surgery - balloon valvuloplasty + valvotomy
46
What is the cause of pulmonary / tricuspid disease?
due to post-inflammatory scarring rheumatic heart disease IVDU endocarditis carcinoid syndrome
47
What are the symptoms of tricuspid disease?
symptoms of right heart failure
48
When is tricuspid stenosis heard?
MID DIASTOLIC murmur
49
When is tricuspid regurg heard?
Pan-systolic
50
When is pulmonary stenosis heard?
Ejection systolic | N.B in MCQ if you get a pan systolic murmur LOUDEST on inspiration - pulmonary stenosis
51
When is pulmonary regurg heard?
Diastolic murmur
52
How is the right heart catheterised?
Peripheral vein: FEMORAL
53
How is the left heart catheterised?
Peripheral ARTERY: femoral
54
What is the cause of eisenmenger's syndrome?
Large L-R shunt causes an increase in pulmonary artery pressure Increased pressure in RHS RHS>LHS therefore blood flows L-R
55
What are the features of eisenmenger's syndrome?
``` Cyanosis SOB Fatigue Chest pain Haemoptysis ```
56
What are the examination findings of Eisenmenger's syndrome?
RV heave Clubbing Cyanosis
57
What re the cause of eisenmenger's syndrome?
VSD | PDA
58
What is the management of Eisenmenger's syndrome?
Heart lung transplant
59
What is infective endocarditis?
Infection of the endocardium of the heart | By staph aureus most commonly
60
Who is at risk of infective endocarditis?
Patients with a structural abnormality in their heart e..g value disease, replacements of congenital defects Patients with normal hearts
61
How does Inf Endo occur in structural abnormality?
Normal GI/Skin commensal that enter blood trivially | Become enmeshed in platelet aggregates and lead to abnormal proliferation
62
How does inf endo occur in patients with structurally normal hearts?
acue pathogenic organisms that directly invade valve: IVDU after heart surgery or sepsis
63
What are the RF for infective endocarditis?
Previous IE, Rheumatic fever, prosthetic valves, congenital heart defect, IVDU and piercings
64
What is the presentation of infective endocarditis?
``` FEVER + NEW MURMUR micro-haematuria splenomegaly osler node splinter haemorrhage clubbing Roth spot - pale areas + haemorrhage on retina Janeway lesions ```
65
What Ix do you do for infective endocarditis?
Bloods - FBC, U+E, LFT, CRP, ESR Blood cultures (3 sets) Urinalysis ++ protein, microscopic haematuria ECG CXR Transthoracic echo
66
What are the Major criteria on Dukes?
+ve blood culture | endocardial involvement on echo
67
What are the minor criteria on Dukes?
Predisposition Fever >38 Vascular/Immunological phenomenon Culture/echo not enough for major
68
what are the criteria for diagnosis of infective endocarditis?
2 x major 1 x major and 3 minor
69
What organisms cause infective endocarditis?
staph aureus strep viridian's (20%) strep epidermis (most common post-surgery)
70
Describe the pathology of acute IE?
Bacterial proliferation in valve necrosis of valve tissue perforation of valve acute cardiac failure
71
Describe the pathology of subacute IE?
infective organisms have decreased virulence Gradual onset destruction of valves Stimulation of thrombus formation - systemic embolizaion
72
What are the complication of IE?
``` systemic emboli pulmonary abscesses valvular incompetence CCF Glomerulonephritis ```
73
What is the management of IE?
Empirial - ben-pen, gentamicin and fluclux IV for 4 weeks

CP3 Medicine (19 decks)

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